How to manage a 47-year-old male with a history of Deep Vein Thrombosis (DVT) and anxiety/depression who wants to discontinue Xarelto (rivaroxaban) due to headaches?

From the Guidelines

The patient should not discontinue Xarelto without consulting his healthcare provider and exploring alternative anticoagulation options, as abrupt discontinuation increases the risk of thrombosis. Management of this 47-year-old male with DVT history and anxiety/depression who wants to discontinue Xarelto due to headaches requires careful consideration of alternative anticoagulation options.

Alternative Anticoagulants

• Apixaban (Eliquis) 5mg twice daily
• Edoxaban (Savaysa) 60mg daily may cause fewer headaches while providing similar protection, as suggested by the NCCN clinical practice guidelines in oncology 1.

Additional Considerations

• Low molecular weight heparin (enoxaparin) or warfarin are also options, though warfarin requires regular INR monitoring with a target of 2-3.
• If headaches persist across multiple anticoagulants, consider a comprehensive headache evaluation and potential prophylactic treatments like acetaminophen or non-NSAID pain relievers (NSAIDs increase bleeding risk).
• The duration of anticoagulation therapy depends on whether this was a provoked or unprovoked DVT, with unprovoked cases often requiring longer treatment, as recommended by the american society of hematology 2020 guidelines for management of venous thromboembolism 1.
• Anxiety and depression should be addressed concurrently as they may influence symptom perception and medication adherence.
• Lifestyle modifications including regular exercise, compression stockings, adequate hydration, and avoiding prolonged immobility can complement medical therapy and reduce recurrence risk.

From the Research

Patient Assessment

• The patient is a 47-year-old male with a history of Deep Vein Thrombosis (DVT) to the left femoral and popliteal vein.
• He also has a history of anxiety and depression.
• The patient is currently taking Xarelto (rivaroxaban) but wants to discontinue it due to headaches.

Treatment Considerations

• According to 2, extended anticoagulation is beneficial for patients with unprovoked proximal DVT or pulmonary embolism (PE), but the decision to continue anticoagulation should be based on the individual patient's risk of recurrence and bleeding.
• 3 suggests that the duration of anticoagulant treatment should be based on the estimated individual risk for recurrent VTE, and that all patients with acute VTE should receive oral anticoagulant treatment for three months.
• 4 states that VTE should generally be treated for either 3 months or indefinitely, depending on the long-term risk of recurrence, risk of bleeding, and patient preference.

Management Options

• Consider alternative anticoagulants that may have a lower risk of headaches, as suggested by 5.
• Assess the patient's risk of recurrence and bleeding to determine the best course of treatment, as recommended by 2 and 3.
• Discuss the risks and benefits of continuing anticoagulation with the patient, taking into account their history of anxiety and depression, as well as their preference for treatment.

Additional Considerations

• 6 suggests that thrombolytic therapy may be an alternative treatment option for patients with DVT, particularly those with iliofemoral venous thrombosis.
• The patient's history of anxiety and depression should be taken into account when making treatment decisions, as these conditions may impact their ability to adhere to anticoagulant therapy.